The U.S. Congress and Global Health: a Primer
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February 2019 The U.S. Congress and Global Health: A Primer Prepared by: Kellie Moss Kaiser Family Foundation and Jen Kates Kaiser Family Foundation Table of Contents Introduction ................................................................................................................................................... 1 Structure ........................................................................................................................................................ 1 Chambers .................................................................................................................................................. 1 Members ................................................................................................................................................... 2 Committees ............................................................................................................................................... 2 Caucuses .................................................................................................................................................. 3 Role and Key Activities ................................................................................................................................. 3 Legislation ................................................................................................................................................. 3 Oversight ................................................................................................................................................... 8 Examples of Congressional Engagement ................................................................................................... 11 PEPFAR .................................................................................................................................................. 11 West Africa Ebola Outbreak .................................................................................................................... 12 Looking Ahead ............................................................................................................................................ 14 Appendix A: Key Congressional Committees and Subcommittees Related to Global Health .................... 15 Appendix B: Key Congressional Caucuses Related to Global Health ........................................................ 18 Endnotes ..................................................................................................................................................... 19 Introduction The U.S. Congress, the legislative body of the U.S. government (USG), plays an important role in determining and shaping the government’s global health policy and programs. Although only one of many USG entities involved in global health, its engagement has been particularly notable over the last 15 years, which have been marked by unprecedented bipartisan support for U.S. global health efforts and resulted in the authorization of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. government’s coordinated response to global HIV and the largest program focused on a single global health issue in the world, as well as the appropriation of significantly increased funding. Indeed, Congress fulfills a key role in U.S. global health policy by setting the broad parameters and priorities of U.S. global health programs, determining their funding levels, and overseeing the implementation and effectiveness of supported efforts. Its activities in this area are complemented and influenced to varying degrees by those of numerous stakeholder groups and individuals that, while not examined in this primer, are key actors in the policymaking process. Such stakeholders include: advocates, the private sector, think tanks, academic institutions, religious communities and organizations, people directly affected by global health issues (such as people living with HIV), and others. To help shed light on Congress’ role in global health, this primer provides an overview of its engagement in this area, aiming to provide a basic framework with which congressional efforts may be understood. First, it examines the structure of Congress and its role and key activities in global health, which range from authorizing the creation of and providing funding for U.S. global health programs to engaging in program oversight and confirming presidential appointees to lead these efforts. It then illustrates these by examining selected legislative activities for two global health examples: the creation and evolution of PEPFAR and the 2014/2015 Ebola outbreak in West Africa. Finally, it discusses opportunities and challenges related to congressional engagement in global health going forward. Structure Congressional engagement in global health is carried out by the two chambers of Congress – the U.S. House of Representatives and the U.S. Senate – and their members, committees, and caucuses. This work is supported by a cadre of congressional staff as well as legislative branch agencies and offices (e.g., the Congressional Budget Office (CBO), the Government Accountability Office (GAO), and the Congressional Research Service (CRS)). Chambers The U.S. House of Representatives (the House) and the U.S. Senate (the Senate) debate and vote on legislation, including legislation related to global health, among other activities. The House is the larger body, whose members represent 435 congressional districts, which are distributed across states based on population during the most recent census; House members are up for re-election every two years. The Senate has 100 members, two from each state, who are up for re-election every six years. The U.S. Congress and Global Health: A Primer 1 Members Each chamber is made up of Box 1: The 116th Congress individuals who have been elected Every two years, a new term of Congress is convened, initiating a new to serve as members of Congress two year period of legislative activity. Each year within this period is a th for certain periods of time (see congressional session. The current Congress, known as the 116 Congress, was convened on January 3, 2019, and will end on January 3, Box 1). Members’ engagement in 2021. Its membership is made up of the following: global health may include a variety Representatives: 435 elected members1 of the House who serve two– of actions, such as: sending official year terms; all are up for election every two years. correspondence (e.g., to the Senators: 100 members of the Senate who serve six-year terms; a Executive Branch or to third of senators are up for election every two years. congressional colleagues Democratic majority in House, Republican majority in Senate: The House has 198 Republicans and 235 Democrats.* The Senate has 53 individually or via “Dear Republicans, 45 Democrats, and 2 Independents who caucus with the Colleague” letters2), speaking Democrats. publicly and/or privately, Members who are: women (131); African-Americans (58); Hispanic or Latino (45); of Asian, South Asian, or Pacific Islander ancestry (18); participating in congressional American Indian (Native American) (4). delegations to the field, issuing Members who served or are serving in the U.S. military: 96. press releases, introducing or co- NOTES: As of February 5, 2019. * One House member recently resigned to sponsoring legislation, and, most pursue a job in the private sector, and another House seat has not been filled since the election results have not yet been certified. importantly, voting on legislation. (It is important to keep in mind that legislation may be a product of negotiations with the Executive Branch.) Committees Within each chamber, the work of Congress is generally performed by smaller groups of members, known as committees. Committees examine issues under their jurisdiction and may also consider and vote on legislation. Passage of a piece of legislation by a committee allows it to be brought before the chamber as a whole. Currently, the Senate has 16 standing (permanent) committees and four select and special committees, which may be permanent or temporary and typically “examine emerging issues that do not fit clearly within existing standing committee jurisdictions or cut across jurisdictional boundaries.” The House has 20 standing committees and three select committees.3 Additionally, there are four joint committees of the House and Senate, which are permanent, bicameral entities that do not consider legislation but rather carry out studies and certain administrative functions for Congress. Although the organization of committees in each chamber is rooted in a 1946 law that originally laid out similar committees in each chamber, the committee structure has evolved over time, leading to more variation across committees and chambers.4 There are more than ten congressional committees whose work relates to global health,5 although a smaller subset of six committees has primary jurisdiction over most global health programs and funding. These six are: the House Committee on Foreign Affairs (HFAC), the Senate Committee on Foreign Relations (SFRC), the House Committee on Energy and Commerce (E&C Committee), the Senate Committee on Health, Education, Labor, and Pensions (HELP Committee); and the House and Senate Committees on Appropriations (Approps. Committees). See Table 2 for an overview of jurisdiction by The U.S. Congress and Global Health: A Primer 2 committee. Also see Appendix A for an overview of key committees and